Annals of Thoracic Medicine Official publication of the Saudi Thoracic Society, affiliated to King Saud University
 
Search Ahead of print Current Issue Archives Instructions Subscribe e-Alerts Login 
Home Email this article link Print this article Bookmark this page Decrease font size Default font size Increase font size


 
ORIGINAL ARTICLE
Year : 2009  |  Volume : 4  |  Issue : 1  |  Page : 21-24
A neglected problem of developing countries: Noncystic fibrosis bronchiectasis


1 Department of Pediatric Allergy, Dokuz Eylul University Medical School, Balcova, 35340, Izmir, Turkey
2 Department of Radiology, Dokuz Eylul University Medical School, Balcova, 35340, Izmir, Turkey

Date of Submission26-Aug-2008
Date of Acceptance25-Sep-2008

Correspondence Address:
Arzu Babayigit
Department of Pediatrics, Dokuz Eylul University Medical School, Division of Allergy, Balcova, 35340, Izmir
Turkey
Login to access the Email id


DOI: 10.4103/1817-1737.44781

PMID: 19561918

Get Permissions

   Abstract 

Background:Bronchiectasis has been defined as the abnormal and permanent dilation of the bronchi. It is still an important problem in many developing countries.
Aim:The aim of this study was to identify the chacteristics and underlying etiology of children followed with the diagnosis of noncystic fibrosis bronchiectasis.
Materials and Methods:Children with bronchiectasis confirmed with high-resolution computed tomography were enrolled into the study. The data of the patients, including symptoms of the disease, age at the onset of symptoms, findings of physical examination, labrotory investigations performed in order to identify the etiology of bronchiectasis, etiology of bronchiectasis if found, radiologic findings and treatment modalities were noted.
Results: Sixty-six children between 1 and 17 years were included in the study retrospectively. Forty-four of them were males (66.7%) and 22 (33.3%) were females. The most common presenting symptoms were cough (100%) and sputum expectoration (50%). An underlying etiology was identified in 44 (66.7%) of the study subjects. The four most common underlying causes were found as infections (21.2%), asthma (16.7%), aspiration syndromes and/or gastroesophageal reflux disease (9.1%) and immunodeficiency syndromes (7.6%), respectively.
Conclusion:Identifying an underlying etiology will have a significant effect on the management of noncystic fibrosis bronchiectasis. Defining the cause of bronchiectasis may also decrease its incidence, progression and complications.


Keywords: Children, etiology, noncystic fibrosis bronchiectasis


How to cite this article:
Babayigit A, Olmez D, Uzuner N, Cakmakci H, Tuncel T, Karaman O. A neglected problem of developing countries: Noncystic fibrosis bronchiectasis. Ann Thorac Med 2009;4:21-4

How to cite this URL:
Babayigit A, Olmez D, Uzuner N, Cakmakci H, Tuncel T, Karaman O. A neglected problem of developing countries: Noncystic fibrosis bronchiectasis. Ann Thorac Med [serial online] 2009 [cited 2014 Nov 25];4:21-4. Available from: http://www.thoracicmedicine.org/text.asp?2009/4/1/21/44781


Bronchiectasis is a progressive condition characterized by irreversible dilatation of the airways. This disease is considered as an orphan either because it is rare or because it is more prevalent in developing countries than in the developed world. Bronchiectasis unrelated to cystic fibrosis was termed an "orphan disease". [1],[2] The prevalence of bronchiectasis is not well characterized. Altough improved sanitation and nutrition, introduction of childhood immunization, particularly against pertussis and measles, and the early and frequent use of antibiotics resulted in a decline in the prevalence of bronchiectasis, [3] the disease is still a problem in developing countries like our country, Turkey. [4],[5],[6] As bronchiectasis is now rare in many developed countries, this has lead to limited research and treatment development on this condition. Over the past years, there have been relatively few studies that have assessed the clinical features of bronchiectasis in childhood.

The aim of this study was to determine the characteristics of children with noncystic fibrosis bronchiectasis and to evaluate the etiologic factors that cause the disease.


   Materials and Methods Top


Children followed with the diagnosis of bronchiectasis at the Dokuz Eylul University Hospital Pediatric Allergy Department in Izmir, Turkey, between 2003 and 2008 were included in the study retrospectively. The diagnosis of bronchiectasis was confirmed radiologically by high-resolution computed tomography (HRCT) for every patient. The following information was found from the patient's file: age at the onset of symptoms, symptoms of the disease such as sputum production, cough, hemoptysis, failure to thrive, history of childhood respiratory infections, history of recurrent wheezing and family history of chronic respiratory disorders. The findings of physical examination, including oscultation findings and presence of clubbing and chest deformity, were also noted. Because HRCT is accepted as the gold standard for diagnosis of bronchiectasis, all patients in the study group were selected from children in whom the diagnosis was confirmed by HRCT. Sweat chloride tests were performed in all patients in order to exclude cystic fibrosis. In the selected patients, genetic mutation analysis for cystic fibrosis was also performed. Serum levels of immunoglobulin (Ig) A, subgroups and total G, M, E and alfa-1 antitrypsine were obtained. All patients aged more than 6 years performed pulmonary function tests with spirometry. Flexible fiberoptic broncoscopy was performed in selected cases (15 of the patients) in whom the etiology of bronchiectasis could not be found in order to exclude foreign body aspiration and to obtain bronchoalveolar lavage fluide for culture. Foreign body aspiration was not detected in our study group.

Patients who had symptoms of swallowing problems and gastroesophageal reflux were investigated by barium fluoroscopy or/and gastroesophagial reflux scintiscans.

Primary ciliary dyskinesia was diagnosed with history of recurrent sinusitis, otitis, pneumonias, presence of situs inversus totalis in two patients, and their ciliary ultrastructures were also evaulated by electron microscopy on nasal epithelial biopsies.

Patients were followed-up with medical treatments including antibiotic use in exacerbations, mucolytics, bronchodilators and chest physiotherapy. Inhaled steroids were given to patients who had bronchial hyperreactivity and positive bronchodilator reversibility. Surgery (lobectomy) was performed in only four patients who had recurrent lower respiratory tract infections and localized disease.

Statistical analysis

The SPSS Inc., 233 S. Wacker Drive, 11 th Floor, Chicago, IL 60606-6307, 11.0 statistical package for Windows was used throughout the study. Results were shown as mean±SD.


   Results Top


Sixty-six children who had diagnosis of bronchiectasis confirmed with HRCT were retrospectively included in our study. Forty-four of them were males (66.7 %) and 22 (33.3 %) of them were females. Mean age of the patients was 9.20 ± 4.38 years (range 1-17 years) at presentation and they had been symptomatic for 4.30 ± 4.14 years (range 0.5-15 years). The most common presenting symptom was cough (100%) followed by sputum expectoration (50%). Hemoptysis history was detected in only three (4.5%) of our patients. Symptom history at the time of diagnosis in our study group is given in [Table 1].

On physical examination, cracles were detected in 72.7% and ronchi in 15.1% of the children. Clubbing was present in 22.7% of the study group. The physical examination findings of our study population are summarized in [Table 2].

Forty-two (63.6%) of the children were able to do pulmonary function tests. 85.7% of them had abnormal function tests. Fourteen patients (33.3%) had obstructive lung changes, five (11.9%) had restrictive lung changes and 17 (40.5%) had combined obstructive and restrictive lung changes.

An underlying etiology was identified in 44 (66.7%) of our patients [Table 3]. The four most common underlying etiologies in our patients were found as infections (21.2%), asthma (16.7%), aspiration syndromes (9.1%) and immunodeficiency syndromes (7.6%), respectively. In five immunodeficient children with bronchiectasis, deficiency of Ig A, deficiency of Ig G2, deficiency of both IgA and IgG2, deficiency of Ig M and common variable immune deficiency were detected, respectively.

In the radiologic findings of the patients (CT findings), 42 children (63.6%) had only one affected lobe, most commonly the left lower lobe (42.4%) [Table 4]. Thirteen of the cases (19.7%) had two lobes involved, whereas 11 patients (16.7%) had three or more lobes involved.

The treatment modalities used by children include bronchodilators (16.7%), mucolytics (24.2%), inhaled steroids (25.2%), combination of bronchodilators and mucolytics (16.7%) and chest physiotherapy (50%). Ten of the patients (15.2%) were not using any medical treatments. Surgery (lobectomy) was performed in only four patients (6%) who had recurrent pneumonias and localized disease. One of these patients who had lobectomy performed also had a history of recurrent hemoptysis.


   Discussion Top


Bronchiectasis was first described as ''production of fetid sputum along with bronchial dilatation''. [7] It is a pathological description of a disease process that has many possible causes. In a previous large series, the majority of the cases were due to extrinsic factors, especially childhood respiratory infections, as the cause of permanent bronchial damage. [8] In a study by Eastham et al, [9] previous respiratory tract infection was found as the most common cause of 93 noncystic fibrosis bronchiectasis cases. Immunodeficiency and bronchiolitis oblierans were the second and third most common reported causes in this study. [9] Karakoc et al, evaulated 23 children with bronchiectasis from Adana, Turkey, and they reported that infections, cystic fibrosis and immunodeficiency syndromes were the most common causes of bronchiectasis. [4] Karadag et al, evaluated 111 children and found postinfectious etiology and immunodeficiencies as the most common causes of noncystic fibrosis bronchiectasis. [5] The etiologic factors underlying childhood bronchiectasis were also investigated with another study from Ankara, and the authors of this study concluded that infections, asthma and primary immunodeficiency syndromes were the three most common causes of noncystic fibrosis bronchiectasis. [6] In the recent years, with early immunization and the widespread use of antibiotics in childhood, postinfectious etiology is likely to be less relevant, especially in developed countries. Based on this information, investigations of intrinsic defects or noninfective extrinsic causes that predispose to bronchial inflammation or infection in more developed areas can be suggested. [8] In our study, we found infections, asthma, aspiration syndromes and immunodeficiency syndromes as the most common causes of bronchiectasis in Izmir. Izmir is the third largest city of Turkey, which has a population of approximately 3.5 million people, located in the western part of the country. Although the socioeconomic status varies widely, most of the people live under hygienic conditions and childhood immunization programmes are well organized. We believe that the more urbanized features of the city of Izmir can explain the lower propotion of infectious etiology in our study group. Bronchial asthma was found as the second common cause of noncystic fibrosis bronchiectasis in this study. This may be due to the underdiagnosis of asthma in children with only cough who had no wheeze or pulmonary oscultation findings. We believe that untreated bronchial inflammation may lead to bronchiectasis in this group of patients. Aspiration syndromes and gastroesophageal reflux disease were found as the third common cause of bronchiectasis in the current study. In six patients (9.1%), aspiration syndromes and/or gastroesophageal reflux disease were detected as the cause of bronchiectasis in this study. Two of these patients were mentally retarded, and it was learnt that thay were hopitalized many times because of aspiration pneumonias. The remaining four children without neurological defects were diagnosed as with gastroesophageal reflux disease. There is evidence that gastroesophageal reflux disease in children without neurological defects is associated with a several-fold increase in the risk of sinusitis, laryngitis, asthma, pneumonia and also bronchiectasis. [10]

The majority of the clinical studies reported that bronchiectasis patients had symptoms in the preschool years. [7] In 74.2% of our study group, clinical symptoms had begun before the age of 5 years. Cough and sputum production were the major symptoms in our study, which is consistent with other reports in the literature. [3],[7] Hemoptysis is a frequent symptom in adult bronchiectasis patients, but it is relatively uncommon in children. [11] Only three patients (4.5 %) in our study group suffered from hemoptysis. One of these patients who had recurrent massive hemoptysis and pneumonias had undergone surgery.

In the diagnosis of bronchiectasis, chest radiographs usually have nonspecific findings of increased lung markings. [12] HRCT has proven to be a reliable and noninvasive method for the assessment of bronchiectasis. [13],[14] HRCT can accurately diagnose bronchiectasis, localize and describe areas of parenchymal and bronchiolar abnormality and also mucus plugging. [14],[15] HRCT scanning is the method used in all cases in our study group in order to diagnose bronchiectasis.

Bronchiectasis is most commonly seen in the lower lobes, especially in the left lower lobe. The upper lobes are affected less frequently, except in cystic fibrosis, probably because of the faciliated mucociliary clearance by gravity. [4],[6] In our study group, after the left lower lobe (42.4%), right middle lobe (25.8%), lingula (25.8%) and right lower lobes (22.7%) were the the other more affected three lobes, respectively.

In conclusion, we emphasized that identification of the underlying cause is the most important step in the treatment and prevention of bronchiectasis. Earlier diagnosis of even milder disease will also change the outcomes and decrease the morbidity and mortality of disease. Research needs urgently to be encouraged and bronchiectasis should not be an orphan any more. We were able to determine the etiology of bronchiectasis in 66.7% of our patients and infections, asthma, aspiration and immunodeficiency syndromes were found to be the most common causes of noncystic fibrosis bronchiectasis in our study population.

 
   References Top

1.Lewinston NJ. Bronchiectasis. In: Hilman BC, editor. Pediatric respiratory disease. Philadelphia: WB Saunders Company; 1993.  Back to cited text no. 1    
2.Dagli E. Non cystic fibrosis bronchiectasis. Paediatr Respir Rev 2000;1:64-70.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Lewitson N. Bronchiectasis. In: Hilman B, editor. Pediatric respiratory disease. Philadelphia: WB Saunders; 1993. p. 222-9.  Back to cited text no. 3    
4.Karakoc GB, Yilmaz M, Altintas DU, Kendirli SG. Bronchiectasis: Still a problem. Pediatr Pulmonol 2001;32:175-8.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Karadag B, Karakoc F, Ersu R, Kut A, Bakac S, Dagli E. Non-cystic-fibrosis bronchiectasis in children: A persisting problem in developing countries. Respiration 2005;72:233-8.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Dogru D, Nik-Ain A, Kiper N, Gφηmen A, Ozcelik U, Yalcin E, et al . Bronchiectasis: The consequence of late diagnosis in chronic respiratory symptoms. J Trop Pediatr 2005;5:362-5.  Back to cited text no. 6    
7.Brown MA, Leman RJ. Bronchiectasis. In: Chernick V, Boat T, editors. Kendig's disorders of the respiratory tract in children. 6th ed. Philadelphia, W.B. Saunders; 1998. p. 538-60.  Back to cited text no. 7    
8.Li AM, Sonnappa S, Lex C, Wong E, Zacharasiewicz A, Bush A, et al . Non-CF bronchiectasis: Does knowing the aetiology lead to changes in management? Eur Respir J 2005;26:8-14.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Eastham KM, Fall AJ, Mitchell L, Spencer DA. The need to redefine non-cystic fibrosis bronchiectasis in childhood. Thorax 2004;59:324-7.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.El-Serag HB, Gilger M, Kuebeler M, Rabeneck L. Extraesophageal associations of gastroesophageal reflux disease in children without neurologic defects. Gastroenterology 2001;12:1294-9.   Back to cited text no. 10    
11.Ferkol TW, Davis PB. Bronchiectasis and bronchiolitis obliterans. ?n: Taussig LM, Landau LI, Le Souλf PN, Morgan WJ, Martinez FD, Sly PD, editors. Pediatric Respiratory Medicine. St Louis: Mosby; 1999. p. 784-9.  Back to cited text no. 11    
12.Currie DC, Cooke JC, Morgan AD, Kerr IH, Delany D, Strickland B, et al . Interpretation of bronchograms and chest radiographs in patients with chronic sputum production. Thorax 1987;42:278-84.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.McGuinness G, Naidich DP. CT of airways disease and bronchiectasis. Radiol Clin North Am 2002;40:1-19.  Back to cited text no. 13  [PUBMED]  
14.Hansell DM. Bronchiectasis. Radiol Clin North Am 1998;36:107-28.  Back to cited text no. 14  [PUBMED]  
15.Brody AS. Cystic fibrosis: When should high-resolution computed tomography of the chest be obtained? Pediatrics 1998;101:1071.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Emerging drugs for bronchiectasis
Anne B Chang,Robyn L Marsh,Heidi C Smith-Vaughan,Lucas R Hoffman
Expert Opinion on Emerging Drugs. 2012; 17(3): 361
[Pubmed]
2 Non-cystic fibrosis bronchiectasis
Smith, M.P.
Journal of the Royal College of Physicians of Edinburgh. 2011; 41(2): 132-139
[Pubmed]



 

Top
Print this article  Email this article
 
  Search
 
   Next article
   Previous article 
   Table of Contents
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (729 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Materials and Me...
    Results
    Discussion
    References
    Article Tables

 Article Access Statistics
    Viewed2875    
    Printed196    
    Emailed0    
    PDF Downloaded473    
    Comments [Add]    
    Cited by others 2    

Recommend this journal